C.P. Negri, OMD, NMD
235 High St.
Morgantown, WV 26505
℡ 304.296.6606
Infinity Health Care provides high quality, comprehensive wellness programs that are unique for
the area. In order to do the best possible job, we must have the most accurate information to begin
with. Please take the time and care to fill out this entire form. If fields are left unanswered, your
form will not be processed. This wide-ranging, confidential questionnaire is used to create a partial
analysis of your case before you are even seen in the office. Because we must do work on your case
in advance, please meet us halfway and spend the time to do your part. We believe it will be worth
your effort.
PATIENT INFORMATION
PLEASE PRINT
Today’s Date _____________
Name ______________________________________
Address ____________________________________
City_______________________
State______ Zip____________
Email address________________________________
Sex: M F Age ____ Birth date ____________
Weight _________Time of birth (if known) _____________
Place of birth_________________________________
Single Married Widowed
Separated Divorced
SS# _______________________________________
Occupation _________________________________
Employer ___________________________________
Employer Address ____________________________
Employer Phone _____________________________
Spouse’s Name ______________________________
Birthdate ____________ SS# __________________
Spouse’s Employer____________________________
Whom may we thank for referring you? ____________
____________________________________________
PAYMENT
Who is responsible for this account? ________________
Relationship to Patient: _________________________
I understand that I am financially responsible for all charges. I
authorize the use of this signature on all insurance
information requests.
_________________________________________
Responsible Party Signature
_________________________ _______________
Relationship
Date
Dr. Negri is a former provider for PEIA, Blue Cross/Blue
Shield, and other insurance companies. Due to constant
policy problems with these companies first reimbursing, then
not covering our services, we discontinued billing insurance in
June 2005. If you wish to submit a claim to your insurance
company we will provide you with the properly coded receipt
of services to send them. Please let the doctor know in
advance of each visit that you will be submitting your
paperwork to your insurance companies.
We accept Visa, MasterCard and debit cards.
We DO NOT accept Discover.
Below is my credit card information required to process
this form, unless a personal check is attached, along with
signature authorizing us to charge this account for the
non-refundable deposit of $100.00. If you are denied as a
patient, your money will be refunded.
_________________________ ________/______
Card #
Exp. Date
_________________________________________
Signature
PHONE NUMBERS
Home _________________Cell_________________
Work ____________________________ Ext. _____
Best time and place to reach you ________________
____________________________________________
IN CASE OF EMERGENCY, CONTACT:
Name ________________________________
Relationship ___________________________
Home Phone __________________________
Work Phone ___________________________
ACCIDENT INFORMATION
Is condition due to an accident?
Yes No Date of accident______________
Type of accident
Auto Work Home
Other ________________________________
To whom have you made a report of your accident?
Auto Insurance Employer
Worker Comp. Other _________________
Attorney Name (if applicable) _________________
Family History
Check illnesses which have occurred in any of your family blood relatives:
diabetes
cancer
bleeding tendency
kidney disease
tuberculosis
heart disease
stroke
high blood pressure
nervous illness
allergy
other ___________________
Why are you here and what would you like to accomplish with our help?
_________________________________________________________________________________________
_________________________________________________________________________________________
Your Health History
SYMPTOMS Check () symptoms you currently have or have had in the past year. You must check either
Yes or No.
GENERAL
1.
Yes
2.
Yes
3.
Yes
4.
Yes
5.
Yes
6.
Yes
7.
Yes
8.
Yes
9.
Yes
10.
Yes
11.
Yes
12.
Yes
13.
Yes
14.
Yes
15.
Yes
16.
Yes
17.
Yes
18.
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
19.
20.
Yes No
Yes No
21.
22.
23.
Yes No
Yes No
Yes No
Anxiety
Catch colds easily
Chills
Confusion
Depression
Difficult concentration
Dizziness
Fainting
Fatigue
Fever
Forgetfulness
Headache
Indecision
Irritability
Migraine
Nervousness
Numbness
Sensitive to weather
changes
Trouble falling asleep
Fall asleep but awaken
later
Sweats
Weight gain
Weight loss
Is there one emotion you experience more often
than others (Mark only one):
24.
Yes No Anger
25.
Yes No Joy
26.
Yes No Worry
27.
Yes No Sadness
28.
Yes No Fear
Which weather do you find less tolerable?
Hot Cold Neither Both
Any thoughts, ideas, fears that you have often?
___________________________________
___________________________________
Any recurring dreams?
___________________________________
___________________________________
Any recurring nightmares?
___________________________________
___________________________________
EYE, EAR, NOSE, THROAT
29.
Yes No Allergies / Hay fever
30.
Yes No Bleeding gums
31.
Yes No Blurred vision
32.
Yes No Dry eyes
33.
Yes No Runny eyes
34.
Yes No Double vision
35.
Yes No Difficulty swallowing
36.
Yes No Earache
37.
Yes No Ear discharge
38.
Yes No Sore throat
39.
Yes No Hoarseness
40.
Yes No Loss of hearing
41.
Yes No Nasal congestion
42.
Yes No Nosebleeds
43.
Yes No Ringing in ears
44.
Yes No Sinus problems
45.
Yes No Vision—Flashes
46.
Yes No Vision—Halos
2
RESPIRATORY
47.
Yes No
48.
Yes No
49.
Yes No
50.
Yes No
Asthma
Cough
Shortness of breath
Wheezing
GENITOURINARY
51.
Yes No Blood in urine
52.
Yes No Frequent urination
53.
Yes No Lack of bladder control
54.
Yes No Painful urination
How often do you urinate daily?________
GASTROINTESTINAL
55.
Yes No Appetite poor
56.
Yes No Belching
57.
Yes No Bloating
58.
Yes No Bowel changes
59.
Yes No Canker sores inside mouth
60.
Yes No Constipation
61.
Yes No Diarrhea
62.
Yes No Excessive hunger
63.
Yes No Excessive thirst
64.
Yes No Gas (flatulence)
65.
Yes No Hard stools
66.
Yes No Hemorrhoids
67.
Yes No Indigestion
68.
Yes No Nausea
69.
Yes No Reflux
70.
Yes No Rectal bleeding
71.
Yes No Soft stools
72.
Yes No Stomach pain
73.
Yes No Vomiting
74.
Yes No Vomiting blood
How often do you have a bowel movement?
What foods / flavors do you strongly dislike?
What foods / flavors do you crave?
CARDIOVASCULAR
75.
Yes No
76.
Yes No
77.
Yes No
78.
Yes No
79.
Yes No
80.
Yes No
81.
Yes No
82.
Yes No
Chest pain
High blood pressure
Irregular heart beat
Low blood pressure
Poor circulation
Rapid heart beat
Swelling of ankles
Varicose veins
MUSCLE/JOINT/BONE
Pain, weakness, numbness in:
83.
Yes No Arm
84.
Yes No Back
85.
Yes No Feet or ankles
86.
Yes No Hands
87.
Yes No Hips
88.
Yes No Knees
89.
Yes No Legs
90.
Yes No Neck
91.
Yes No Fracture easily
92.
Yes No Strained muscles
93.
Yes No Sprained ligaments
SKIN
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
Yes No Acne
Yes No Bruise easily
Yes No Cold sores on lips
Yes No Dry skin
Yes No Eczema
Yes No Flaky scalp
Yes No Heavy perspiration
Yes No Hives
Yes No Itching
Yes No Oily skin
Yes No Psoriasis
Yes No Rash
Yes No Rosacea
Yes No Scanty perspiration
Yes No Scars
Yes No Sore that won’t heal
Yes No Warts
Are your fingernails:
Yes No Soft
Yes No Splitting
Yes No Ridged, brittle
Yes No Discolored
3
MEN ONLY
115.
Yes No Breast lump
116.
Yes No Erection difficulties
117.
Yes No Lump in testicles
118.
Yes No Penis discharge
119.
Yes No Sexual difficulties
120.
Yes No Sore on penis
Other________________
WOMEN ONLY
121.
Yes No
122.
Yes No
123.
Yes No
124.
Yes No
125.
Yes No
126.
Yes No
127.
Yes No
128.
Yes No
Abnormal Pap Smear
Bleeding between periods
Irregular periods
Breast lump
Nipple discharge
Fibrocystic breasts
Extreme menstrual pain
Premenstrual syndrome
129.
130.
131.
132.
133.
134.
135.
136.
Yes No Hot flashes
Yes No Fibroid tumors
Yes No Ovarian cysts
Yes No Ovarian pain
Yes No Painful intercourse
Yes No Sexual difficulties
Yes No Vaginal discharge
Yes No Yeast infections
Other__________________
Date of last menstrual period ___________
Number of pregnancies ________
Number of children ________
Are you pregnant? Yes No
Date of last Pap Smear _______________
Have you had a mammogram?
Yes No Date__________
CONDITIONS Check () conditions you currently have or have had in the past year. You must check
either Yes or No.
137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
High Cholesterol
HIV Positive
Jaundice
165.
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
182.
183.
184.
185.
186.
187.
188.
189.
190.
191.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Nervous Disorder
Osteoporosis
Pacemaker
Pneumonia
Polio
Prostate Problem
Psychiatric Care
Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempt
Syphilis
Thyroid Problems
Tonsillitis
Tuberculosis
Typhoid Fever
Ulcers
Vaginal Infections
Vein Trouble
4
EXERCISE
WORK ACTIVITY
None
Moderate
Daily
Heavy
Sitting
Standing
Light Labor
Heavy Labor
HABITS
High Stress Level
Smoking
Alcohol
Coffee/Caffeine Drinks
Soda Pop
DIET soda
Marijuana*
Reason ___________
__________________
Packs per Day _____
Drinks per Week ____
Amount/Day _______
Amount/Day _______
Amount/Day _______
Amount/Week ______
*This substance can interfere with some of my treatments,
so I appreciate your being honest about this.
Injuries/Surgeries you have had
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries
Description
Year
Yes No Have you ever had any allergic reactions to shellfish?
Yes No Are you allergic to Novocain or Xylocaine?
Yes No Do you have allergic reactions to latex?
Please list any allergies known to you.
ALLERGIES
(foods, molds, etc.)
Please list below your current medications and any supplements you take.
If you take none please indicate that in each column.
PRESCRIPTION MEDICATIONS
VITAMINS/HERBS/MINERALS
Pharmacy Name:
Pharmacy Phone:
5
Select the statement that best describes your dietary habits.
Which statement best describes your daily eating routine?
I try to eat the traditional three meals daily.
I try to eat several small meals and only seldom a large meal.
I snack often and seldom eat a full meal.
I eat only one to two meals a day.
My meal schedule is highly irregular, alternating between one meal a day with several snacks to two or
three large meals a day.
Which statement best describes your preference for eating dessert?
I almost always have desserts after my meals.
I often, but not always, have desserts after meals.
I occasionally have desserts after meals.
I seldom have desserts after meals.
I avoid having dessert.
What best describes how your eating patterns have changed, as you get older?
I continue to eat about the same as before.
I have increased my food intake.
I have decreased my food intake.
I eat the same total amount, but smaller and more frequent meals.
I am on a medically prescribed diet.
How often do you eat breakfast?
Never
Always
Occasionally
Most of the time
How often do you eat at "fast food" restaurants?
Most of the time.
About once a day.
Three to four times a week.
Once or twice a week.
Hardly ever.
Answer True or False to the following statements:
T F
I often snack between meals.
I routinely try new weight-loss diets.
My eating habits are about the same as my parent’s eating habits.
I often overeat at dinner.
I take vitamin and mineral supplements for adequate nutrition.
I eat a wide variety of foods.
I eat only “fresh" foods.
I consciously limit the calories I eat
I seldom eat desserts.
I eat only certified organically grown foods.
I have a kosher or equivalent type of diet.
I am on a medically supervised diet schedule.
I am a vegetarian.
I am a vegan.
I eat whatever is around or available.
I am mindful of what I eat and try to be careful.
6
Which of the following best describes your red (beef, pork, lamb, and veal) meat-eating habits?
I don't eat red meat.
I eat red meat fewer than four times each week
I eat red meat between seven and four times each week.
I eat red meat more than seven times each week.
Which of the following best describes your egg-eating habits?
I don't eat eggs.
I eat fewer than four eggs each week.
I eat between seven and four eggs each week.
I eat more than seven eggs a week.
Indicate your use of dairy products by placing a check in the appropriate blanks:
Average 3 or
Average 1 or
Eat/drink it
more servings daily
2 servings daily
occasionally
Butter
Margarine
Whole milk
Low-fat milk
Hard cheese
Other cheeses
Cream
Ice cream
How often do you have the following items for snacks?
Over 4
3-4 times
1-2 times
Times a day
a day
a day
Soda pop
Diet soda
Candy
Cookies
Cakes
Pies
Potato Chips
Pretzels
Ice cream
Snack cheese
Never
eat/drink it
Daily
Occasionally
Seldom
or never
Which statement best describes the way you use table salt?
I usually add salt before tasting my food.
I occasionally add salt to my food.
I usually add salt because my food is never spicy enough.
I seldom have to add salt to my food.
I make it a rule never to add or cook with salt.
7
How much smoked or cured meats such as bacon, ham, or other prepared or packaged meat products do you
eat?
I eat these products at least once a day.
I eat products such as these three to five times a week.
I eat products such as these at least once a week.
I eat products such as these occasionally.
I don't eat prepared, packaged meat products.
How much coffee or tea do you drink each day?
10 or
7-10 cups 5-6 cups 3-4 cups
more cups
Coffee
Black Tea
Green Tea
Herbal Tea
On the average, how much alcohol do you drink?
10+ drinks
9-10
7-8
5-6
per day
per day
per day
per day
Beer
Ale
Wine
Whiskeys
Gin
Vodka
Bourbon
Cocktails
Liqueurs
Cordials
1-2 cups
3-4
per day
less than
1 cup
don’t
drink
1-2 less than 1 less than 1
per day per day
per week
don’t
drink
Which statement best describes your intake of fats?
I don't worry about fat intake.
I limit my intake of unsaturated fats to 10 percent or less of my total diet.
I eat fats only occasionally, and they are not a regular part of my diet.
I eat no animal fats.
8
Please list your major health concerns in detail:
Problem #1 _____________________________________________________________________
__________________________________________________________________________________
What makes it worse (certain weather, activity, rest, certain foods, etc.)? _______________________
__________________________________________________________________________________
What makes it feel better?_____________________________________________________________
When does it bother you most (time of day, season, before periods, etc.)? _______________________
If your problem causes you pain, describe it as closely as possible:
___ sore, bruised ___ aching ___ cramping, drawing ___ sharp, stabbing ___ burning
Choose ONE: ___ steady ___ throbbing ___ intermittent
Please mark on the 1-10 scale your overall level of pain at present.
MY PAIN IS:
No pain
__________________________________________
0
1
2
3
4
5
6
7
8
9
Unbearable
10
Problem #2 _____________________________________________________________________
__________________________________________________________________________________
What makes it worse? _______________________________________________________________
What makes it feel better? ____________________________________________________________
When does it bother you most? ________________________________________________________
If your problem causes you pain, describe it as closely as possible:
___ sore, bruised ___ aching ___ cramping, drawing ___ sharp, stabbing ___ burning
Choose ONE: ___ steady ___ throbbing ___ intermittent
Please mark on the 1-10 scale your overall level of pain at present.
MY PAIN IS:
No pain
__________________________________________
0
1
2
3
4
5
6
7
8
9
Unbearable
10
Problem #3 _____________________________________________________________________
__________________________________________________________________________________
What makes it worse? ________________________________________________________________
What makes it feel better? ____________________________________________________________
When does it bother you most? ________________________________________________________
If your problem causes you pain, describe it as closely as possible:
___ sore, bruised ___ aching ___ cramping, drawing ___ sharp, stabbing ___ burning
Choose ONE: ___ steady ___ throbbing ___ intermittent
Please mark on the 1-10 scale your overall level of pain at present.
MY PAIN IS:
No pain
__________________________________________
0
1
2
3
4
5
6
7
8
9
Unbearable
10
9
Please indicate the appropriate location of your pain and the symbol that best describes the discomfort you are
presently experiencing.
Sharp and stabbing = + + + +
Dull and achy = v v v v
Pins and needles = o o o o
Numbness = / / / /
10